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Home , Pyometra, Vaginal discharge

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Vaginal discharge reviewed: the adult pre-menopausal female Henn EW, MBChB Registrar in the Department of and Kruger TF, MBChB, MPharMed, MMed (O&G), FCOG (SA), FRCOG (London), MD Head of Department of Obstetrics and Gynaecology Siebert TI, MBChB, FCOG (SA), MMed (O&G) Consultant, Department of Obstetrics and Gynaecology, Stellenbosch University and Tygerberg Hospital, Tygerberg 7505

Correspondence: Prof. TF Kruger, Chairman, Dept Obs/Gyn, PO Box 19081, Tygerberg 7505. E-mail: [email protected]

Keywords: , , syndromic management

(SA Fam Pract 2005;47(2): 30-38)

A vaginal discharge is one of the most Syndromic treatment is more What is a normal discharge? common gynaecological symptoms appropriate in the high-risk population A physiological vaginal discharge does affecting women and a very common or the sector with limited resources. exist and consists of secretions from the cause for seeking medical attention. This This is advised due to the significant different cellular and anatomical is especially true during the reproductive complications of not treating, or structures in the reproductive tract. years. In the US, vaginal discharge otherwise inadequately treating, STDs, Vaginal secretions are composed of accounts for more than 10 million office and the loss of follow up of patients. vulvar secretions – from the sebaceous, visits to physicians each year.1 This figure A common clinical misconception is sweat, Bartholin and Skene glands, correlates well with this symptom in South that a vaginal discharge is synonymous transudate from the vaginal walls, African private practice.2 An estimated with a vaginal infection. This is evident exfoliated vaginal and cervical cells, 1% of all outpatient prescribed when one considers the extensive cervical mucous, endometrial and are written to women given this differential diagnosis that needs to be fluids, and micro- diagnosis.3 The woman’s perception as considered in the woman presenting organisms and their metabolic to the cause of the discharge will with a vaginal discharge. In his study of products.16 The type and amount of the influence her choice of medical attention. more than 20 000 women presenting above secretions are determined by In many cases, the woman may have with a perceived abnormal discharge, biochemical processes that are attempted self-treatment of the discharge Fleury found that aetiologies other than influenced by hormone levels. with over-the-counter (OTC) preparations an infective vaginitis were responsible The vaginal desquamative tissue is prior to consulting her doctor. This action for more than a third of all cases.8 made up of vaginal epithelial cells that often leads to an unsuccessful outcome, In developing countries, the are responsive to varying amounts of with the majority using OTC antifungals incidence of sexually transmitted oestrogen and . The phase inappropriately to treat gynaecological diseases (STD) remains very high and of the therefore conditions that are similar, but potentially these patients commonly present with a influences the quantity and quality of more severe.4-6 Consultation is often vaginal discharge. The STD burden is normal discharge. During the follicular delayed due to embarrassment or fear, heaviest in sub-Saharan Africa.9 phase, there is a gradual increase in with most women believing that sexual The management of vaginal and vaginal fluid discharge, peaking at transmission played a role in the cervical infections is especially difficult . After ovulation (luteal phase), transmission of symptoms.7 Vaginal in developing countries due to the limited the discharge becomes more viscous discharge is a non-specific symptom availability of laboratory facilities for and thick. These cyclic variations do not that requires the correct approach to diagnosing these infections. For this occur when oral contraceptives are used be able to make a diagnosis. Although reason, syndrome-based management that result in anovulatory cycles. empiric therapy and a syndromic was introduced by the WHO.10 This Diet, medication and OTC dietary approach based on the woman's should not, however, replace a diagnostic supplements affect the odour of the symptoms and a naked-eye evaluation approach and specific treatment in a normal vaginal discharge. In healthy of the discharge was and is still common medical setting where laboratory access women, the contains 109 bacterial practice, modern management of is available and affordable. colony-forming units/gram of vaginitis demands that a specific The approach of most physicians, secretions.17 The normal is diagnosis be made. In the high risk generalists and specialists included, predominantly aerobic, with the most population or the sector with limited to the management of a vaginal common being Gram-positive resources, syndromic treatment is more discharge is, however, still found to be sp. Physiological appropriate though.69,70 The modern unsatisfactory. This seems to be a global discharge is usually clear or white, management of vaginitis demands that dilemma that is not limited to developing viscous in consistency and located in a specific diagnosis be made in the countries only.11-15 The effective the posterior fornix of the vagina.18 low-risk population and where management of a chronic vulvovaginal Microscopy of normal vaginal laboratory facilities are available. disorder remains challenging. secretions will reveal many superficial

30 SA Fam Pract 2005;47(2) CPD

epithelial cells, lactobacilli with long rods Table I: History Table II: Causes of vaginal discharge and very few white blood cells. Nature of discharge Physiological Colour Physiological discharge History Odour Pregnancy Consistency A thorough and detailed history is Associated irritation or discomfort essential and can be a helpful indicator Sexually transmitted infections of the cause of the vaginal discharge. Timescale Duration Trichomonas vaginalis Traditional ‘typical’ symptoms and signs Variation in relation to menstrual cycle, coitus trachomatis of infectious vaginal discharge are, Factors associated with onset of the Neisseria gonorrhoeae however, not specific and sensitive discharge Herpes simplex infection enough for identification of a specific Human papilloma virus Gynaecological symptoms Human immunodeficiency virus organism and it has, in fact, been shown Smear history to be of limited diagnostic value.19 Mixed Lower abdominal pain (superficial or deep) Other infections genital infections with more than one Associated intermenstrual or post-coital bleed Candida species vulvovaginitis infection present at the same time Vulvar pain, blisters, lesions compound the presentation.20 This is Urinary symptoms Desquamative inflammatory vaginitis Climacteric symptoms Toxic shock syndrome especially true in high-risk populations 21 and HIV-infected patients. Table I lists Sexual history Neoplasms the factors in the history that should be New sexual partner, number of recent Vaginal tumours 22 partners considered. Symptoms in partner Cervical cancer and polyps Previously diagnosed abnormal/infectious Endometrial tumours discharge Differential diagnosis of the Iatrogenic vaginal discharge Other factors Drug induced Table II lists the more frequently OTC or prescribed medications already used Foreign bodies encountered causes of a vaginal to treat Medications, e.g. hormonal drugs, antibiotics Other discharge. Most vaginal symptoms are Retained foreign body Fistula caused by one of three types of Personal hygiene practices, e.g. douching Medical history, e.g. gynaecological surgery, Dermatologic conditions vulvovaginitis: bacterial vaginosis, radiotherapy, possible diabetic symptoms Candida vulvovaginitis and trichomo- Inflammatory bowel disease Psychosomatic vaginitis niasis. Other, less common aetiologies are also encountered. The most common causes shall be discussed. Infectious vaginitis Candida vulvovaginitis as many as 65% of women who believe Physiological Candida vaginitis (CV) ranks as the they have thrush will have a different Pregnancy second most common cause of vaginal condition causing their symptoms.29 Hypertrophy of the vaginal epithelium infection. Approximately 75% of women during pregnancy leads to an increased are estimated to have at least one Physical findings vary from an exudative number of glycogen-containing cells episode of this infection during their syndrome of copious discharge and being shed into the vagina. Women thus reproductive life.24 About 90% of the white plaques on the vaginal walls, to notice an increase in vaginal discharge. infections are caused by Candida minimal discharge and severe erythema Pregnancy may also predispose women albicans species, with the remainder with extensive vulvar involvement. to infective conditions, such as Candida being non-albicans species, mainly C. vulvovaginitis.23 It is important glabratato .23,25 Of the infected women, Diagnosis: The lack of specificity of investigate an offensive, purulent or 40-50% will experience recurrence. Only symptoms and signs in CV precludes bloody discharge, or a discharge with a small subpopulation will suffer chronic a satisfactory diagnosis based on the 26 associated symptoms. Most women can recurrence. It can be a normal clinical picture alone. On the other hand, be assured, however, that an increased asymptomatic colonisation in the positive vaginal cultures may reflect discharge is normal. vagina. colonisation and are not used as the sole basis of diagnosis either. Most Atrophic vaginitis Predisposing factors: Antibiotics, patients with symptomatic vaginitis can Atrophic vaginitis is a symptomatic pregnancy, oral contraceptives, be readily diagnosed on the basis of a vaginal inflammatory condition caused diabetes, high dietary glucose intake, microscopic examination of the by oestrogen-deficient vaginal sexual behaviour, tight synthetic discharge. A wet-mount preparation of underwear and HIV infection.3 There the secretion mixed with 10% KOH, in epithelium. It mostly occurs in 48 postmenopausal women, but should also could also be a genetic predisposition. addition to a saline preparation, is be considered in cases of prolonged examined. The presence of branch-like lactation3 and premature ovarian failure.16 Clinical presentation: The presentation pseudohyphae or budding yeasts are Symptoms include vaginal spotting, typically consists of vulvar pruritus, diagnostic (see Figure 1). The presence vulvar pain,27 terminal dysuria and a of large numbers of white cells would soreness, external dysuria, pruritus, variable vaginal discharge, ranging from suggest a mixed infection. Vaginal pH dyspareunia and an increased vaginal thick, cottage cheese-like to watery. An reveals a normal pH (<4.5). Routine discharge. Signs are a thin, shiny, pale odour is significantly absent in Candida cultures (Sabouraud’s medium or pink vagina with loss of rugae. Treatment infections.19 None of the symptoms is Nickerson’s agar) are unnecessary and consists of intravaginal oestrogen specific to CV or invariably associated should only be performed in the preparations daily for one to two 28 16,18 with disease. Diagnosis based on presence of negative microscopy in weeks. Topical long-lasting lubricants clinical findings alone is unreliable and symptomatic patients.30 are also an option for patients unwilling or unable to use oestrogen. Continued on page 34

32 SA Fam Pract 2005;47(2) CPD

Infectious vaginitis continued

Treatment: Topical imidazole antifungal agents are available or concomitant infection. True recurrence (>4 episodes in a variety of formulations and treatment is highly effective annually) needs to be evaluated further. in the majority of cases. The patients’ preference should guide the choice of therapeutic formulation. Single-dose preparations Figure 1: 10% KOH wet-mount smear demonstrating offer an advantage when compliance is a problem. Fluconazole pseudohyphae of Candida albicans. is the only oral antifungal agent approved for this indication. Resistance to triazoles has been reported on rare occasions, especially in immunocompromised patients.31 Non-albicans species are notorious for their resistance to azole agents. Fungal cultures are best to identify these species. Treatment with Nystatin has been well established.32 Boric acid, 600 mg in a gelatine capsule, used vaginally for 10 days, has also been shown to be highly effective in resistant cases.17 Recurrence is common if the full course of treatment is not completed and is also likely if there are predisposing factors

Bacterial vaginosis Bacterial vaginosis (BV) is the most common vaginal infection 4. Presence of >20% clue cells on wet-mount microscopy among women in their reproductive years, accounting for 40- of the vaginal fluid. 50% of all cases of vaginitis.3,4,20 Because the cause of BV Clue cells, i.e. vaginal epithelial cells with bacteria densely remains unknown, the definition remains imprecise and adhered to them and obscuring their borders, is the single currently relies on the description of the changes that occur. most reliable predictor of bacterial vaginosis (see Figure 2). It reflects an overgrowth of anaerobic organisms causing a The presence of leucorrhoea (>10 white blood cells/HPF) polymicrobial disequilibrium of the vaginal ecosystem. The would suggest a concurrent infection.39 Vaginal pH testing production of amines is responsible for the ‘fishy’ odour is highly sensitive, but not specific.40 Gram staining on an air- characteristic of this condition. BV, although never proven to dried slide of vaginal fluid, using Nugent’s criteria, has been be sexually transmitted, has an epidemiological profile proven to be a reliable diagnostic procedure.41 The diagnostic consistent with that of an STD.33,34 Changes in the vaginal value of a Papanicolaou smear and vaginal culture is limited flora occur most commonly around the time of menstruation because these organisms are members of the normal vaginal and following , and women who suffer flora. In offices where microscopy is not available, commercial recurrent BV often report that the discharge is worse at these diagnostic tests are available, e.g. BVBlue42 and FemExam.43 times.23 BV may be symptomatic or asymptomatic, may occur acutely or episodically, may become persistent, or may resolve Treatment: Treatment options for BV include oral and topical spontaneously. Approximately half of women with BV are formulations containing metronidazole or clindamycin. The asymptomatic. There are no proven individual predisposing seven-day metronidazole course (400mg 8-hrly po) still factors exclusive to BV.26 represents the gold standard of therapy, although shorter courses are as effective in the acute phase (2g stat po). Complications: Many recent studies have shown the relation Vaginal acidification to normalise the flora has been shown of BV to considerably important gynaecological and obstetric to be ineffective.45 How to manage women with continuing complications. Among the gynaecological complications are recurrences still remains unclear and treatment is difficult. It pelvic inflammatory disease,35 abnormal bleeding, has been common practice not to treat asymptomatic BV , postoperative infections following pelvic surgery,36 infection, because evidence suggest that spontaneous and transmission of HIV infection.37,43 Obstetric complications resolution will occur in >75% of patients after a six-month are preterm delivery, mid-trimester miscarriages, and intra- period of observation.44 However, this view has now been and .26 challenged as a result of complications linked to BV. Further work still needs to be undertaken to establish the role of Clinical presentation: The predominant complaint is of an offensive, treating asymptomatic infection, because of the conflicting fishy-smelling, thin vaginal discharge present at the introitus. information in the studies conducted thus far. The odour is often more noticeable after unprotected coitus. The patient will otherwise present with any possible combination Figure 2: Saline wet-mount smear showing clue cells of the already mentioned symptoms of infective vaginitis, hence indicative of bacterial vaginosis (Gardnerella vaginalis). the limited value of diagnosing solely on the history.20

Diagnosis: The diagnosis is based on Amsel’s criteria.38 Three of the following four criteria are necessary to confirm the diagnosis of BV: 1. A raised vaginal pH >4.5 2. Presence of a homogenous thin grey or white discharge coating the vaginal walls. 3. Release of amines on mixing the discharge with 10% KOH, the ‘whiff test’.

Desquamative inflammatory vaginitis This is a rare disorder arising from an unknown cause.46 It is logical pathogen has been identified. Although most cases characterised by diffuse exudative inflammatory vaginitis with are associated with oestrogen deficiency, oestrogen therapy epithelial cell exfoliation, resulting in a profuse, purulent does not induce a therapeutic response. Management is still discharge. Women complain of this discharge, dyspareunia controversial. Good response has been shown with topical and vulvar pain. There is no prominent odour. Examination 2% clindamycin therapy, intravaginally (one to two weeks). reveals an intensely reddened vagina. No consistent microbio- Occasionally, steroids may be required.

34 SA Fam Pract 2005;47(2) CPD

Sexually transmitted infections

Trichomonas vaginalis Trichomonas vaginalis is a unicellular flagellated protozoan Diagnosis: A vaginal pH >4.5 is found in 60% of cases of that is the third most common cause of infectious vaginitis. Trichomonas vaginitis. Microscopic examination of a saline It is an anaerobic parasite that is responsible for 15 to 30% wet-mount preparation of the discharge is essential. of cases.3 It is one of the more common STDs. Non-venereal Trichomonads are pathognomonic and can be identified as transmission has been deemed a possibility due to the small, pear-shaped organisms with highly motile flagellae organism’s isolation outside of the human body in humid (see Figure 3). Increased numbers of leucocytes are also areas. It has been isolated from toilet seats, baths, poorly seen. With negative microscopy, organisms can be cultured chlorinated water, etc.26 There is concomitant BV infection in using Diamond’s medium or Roiron medium. This remains 60% of patients infected with T. vaginalis.16 the gold standard in diagnosing T. vaginalis. Also highly effective, but more expensive, is monoclonal antibody testing Predisposing factors: It is a sexually transmitted disease, with and polymerase chain reaction (PCR) assay.51 transmission being greater from men to women.47 Men clear T. vaginalis at a greater rate and could thus serve as an Treatment: Sexual contacts of women with confirmed infection asymptomatic reservoir and vector for transmission.50 should always be treated. Oral metronidazole remains the is also an important co-factor in amplifying drug of choice, with a single-dose treatment (2g po) being HIV transmission.49 preferred. The longer regimen (400mg 8hrly po, seven days) should be used in women not able to tolerate the high single Clinical presentation: Local immune factors and inoculum dose, and in failed single-dose therapy. True resistance to size influence the appearance of symptoms, with it being metronidazole is rare. Alternative therapies include tinidazole much milder in patients with a smaller inoculum, and often (2g stat) and paromomycin (not available in SA). being asymptomatic in these patients – up to 50%. Figure 3: Saline wet-mount smear showing Trichomonas Approximately 30% of asymptomatic patients become vaginalis with characteristic flagellae. symptomatic in six months. The predictive value of symptoms in trichomonal infection is very low.20 A copious green or yellow vaginal discharge is the presenting complaint for 70% of infected women, and about 50% will complain of an associated offensive odour.23 The discharge may be frothy. Associated symptoms can include the spectrum of infective vaginitis symptoms. Examination of patients with high concentrations of the organism may reveal petechial haemorrhages on the vaginal walls and colpitis macularis, the ‘strawberry’ (only 2%).

Chlamydia trachomatis and Neisseria gonorrhoeae a thin cotton swab stick is placed into the endocervical canal These two sexually transmitted organisms are grouped and then twirled. The finding of yellow mucopus is a positive together, for they are the main causes of a vaginal discharge test for confirmation of infection. The sensitivity of mucopurulent due to infectious . Chlamydial infection is the most cervicitis has been shown to be as low as 30% only.20 The common bacterial STD in the UK.23 C. trachomatis is an microscopic presence of leucorrhoea has been shown to be intracellular organism, infecting the columnar epithelium strongly associated with cervical infection.56 Tissue culture of the endocervical canal and urethra. The infection is is the gold standard diagnosis. Endocervical cultures using asymptomatic in 80% of women.52 N. gonorrhoeae is a DNA probes, PCR assays or ligase chain reaction tests can Gram-negative diplococcus infecting many sites secondary be recommended for both Chlamydia trachomatis and N. to sexual contact. It is asymptomatic in 50% of cases. gonorrhoeae detection. Gonorrhoea can also be cultured in Correct diagnosis and treatment of cervical infection are modified Thayer-Martin media or chocolate agar. Because critical for preventing upper genitourinary tract infection there is a high rate of concurrent infection, any woman being and severe sequelae, and also for preventing further screened for chlamydia should also be screened for transmission.53,54 gonorrhoea.

Clinical presentation: A purulent vaginal discharge, post- Treatment: Uncomplicated chlamydial infection is treated with coital or , dysuria, lower abdominal a course of doxycycline (100mg bid seven days). Single- pain and dyspareunia are encountered. Clinical examination dose azithromycin (1g po) is also effective. Gonorrhoea is might reveal opaqueness of the endocervical discharge, treated with single-dose oral ciprofloxacin (500mg). There yellow discharge and easily induced cervical bleeding.55 are gonorrhoea that are resistant to quinolones, and in such cases single doses of ceftriaxone (125mg im) or spectinomycin Diagnosis: The Q-tip test has been described to test clinically (2g im) can be used. The sexual contacts of infected women for mucopurulent cervicitis. The ectocervix is cleaned gently, should always be treated.

SA Fam Pract 2005;47(2) 35 CPD

Neoplasms underway.58 Until it has been found, the subsequent pelvic examination67 Always consider a malignancy of the recommended approach in resource- provided the highest combination of genital tract in a woman who presents poor countries is syndromic sensitivities and specificities in the with a blood-stained discharge, management.10 The syndromic approach evaluated algorithms.60 especially in the case of older women. is based upon identifying a group of Syndromic management is not to be A persistent vaginal discharge should symptoms and easily recognised signs recommended in the low-risk population also raise this suspicion. The importance that are associated with a number of and where laboratory facilities are available. of a and regular well-defined aetiologies. Once these These resources and diagnostic tools cytological smears need not be have been identified, treatment can be should then be utilised to make a definitive motivated and are both mandatory. provided for the majority of organisms diagnosis.68 In the high-risk population or responsible for the syndrome. These the sector with limited resources, syndromic Iatrogenic syndromic flow charts have been found treatment is more appropriate.69,70 The Drug induced to perform better in males than in Department of Health currently promotes Drugs may cause an allergic or females.9 However, women suffer most syndromic management as appropriate for inflammatory process in the vagina, or from the long-term sequelae of primary care in the majority of South African alter the hormonal environment.23 Due inadequately treated STDs. The settings. to their oestrogen activity, oral advantage of this approach is that it contraceptives have long been allows for the treatment of uncomplicated Non-pharmacological associated with an increased discharge. cases of discharge and genital ulcer management Chemical desquamation and secondary disease by primary health care providers This is an important and often neglected infection can also be caused by a variety with minimal or no laboratory support. part of managing the patient with an of preparations. Examples are condoms, The effectiveness of this type of abnormal vaginal discharge. The spermicides, vaginal creams and management is dependent on proper syndromic approach can only function lubricants, douches and antiseptics. administration, which should ensure that well if it is followed as a whole. the required resources are available to Counselling of all patients being treated Foreign bodies follow the national guidelines of is an absolute requirement. Attention An offensive, sometimes blood-stained syndromic management.59 The provision must be paid to motivating behavioural vaginal discharge should alert one to the of STD treatment in these settings should changes, with the aim to reduce unsafe possible presence of foreign bodies. help de-stigmatise STD control for sexual practices and therefore to reduce Although most common in small children, women. One other important advantage the risk for future STDs. Barrier it can occur in any age group. Women are could be that women would seek contraception (i.e. condoms) is to be often too embarrassed to mention this, or treatment more quickly. Unfortunately, recommended and freely available. The may have forgotten about it. The object the poor performance of the algorithm patient needs to be offered testing as usually leads to vaginal ulceration with for the management of an abnormal well as pre-test counselling for HIV and secondary infection. may vaginal discharge in the primary care syphilis. Partner notification cards or a occur in the case of the presence of long- arena means that this approach will need similarly effective system should be in term foreign objects. It is important to try some rethinking.60 place to ensure adequate treatment of and visualise the whole length of the vagina The control of STDs is an important both parties and the importance of during examination. Management involves strategy in the prevention of HIV completing the prescribed treatment the removal of the foreign body, together infection.61,62 STD counselling in the needs to be re-enforced. with cover for secondary primary care setting is equally important, infection. Psychosomatic causes, although but is often inadequate.63 The high rate A word on over-the-counter drugs unusual, should be kept in mind.57 of over treatment of vaginal discharge and probiotics through the syndromic approach (up to Certain imidazole drugs were released Other 90% in low-risk populations) carries both OTC to enable women to self-medicate Fistula financial and social costs – the latter in a perceived minor complaint and a A history of prolonged obstructive labour, potentially exposing women common infection such as Candida. The radiotherapy, pelvic surgery or misdiagnosed as having an STD to easy access to self-treatment is inflammatory bowel disease should raise threats of domestic disruption or even appealing to the patient, the pharma- a suspicion for the possibility of fistula. violence.64,65 It also encourages antibiotic ceutical providers, medical aid funds, The anatomical defect can be a vesico- resistance and exposes women to the and many clinicians. The crucial aspect vaginal or recto-vaginal fistula. This side-effects of antibiotics.66 of self-medication is that the woman condition needs specialist evaluation Another disadvantage of the vaginal should be able to self-diagnose correctly. and management. discharge (VD) algorithm is that it A few studies have recently addressed requires a woman to present with a VD the inappropriate use of these drugs.4-6 The role of syndromic before she can be evaluated using the The findings were all of a similar and management in vaginal algorithm. When the algorithm is used concerning nature. Nearly all women discharge as a screening test, it has not performed had used the products before. Almost The treatment of STDs in women remains effectively, especially amongst low-risk 66% of women did not have candidiasis, one of the most difficult challenges for populations.60 but another cause for the discharge. control programmes. STDs are most The sensitivities of studies evaluating Previous physician diagnosis did not accurately detected by using the WHO algorithm ranged from 73-93%. improve their ability to correctly diagnose technologically advanced diagnostic The incorporation of a speculum the infection compared with women techniques, which are often expensive examination increased the sensitivity, without a previous diagnosis. Women and require health resources. The search but led to a slight decrease in the who read the package brochure were for a cheap and effective diagnostic tool specificity. The incorporation of the not more likely to have candidiasis than to address this challenge is still symptom of lower abdominal pain and women who did not read it. Many women

36 SA Fam Pract 2005;47(2) CPD

Figure 4: Current South African vaginal discharge guideline. VAGINAL DISCHARGE SYNDROME (VDS)

Patient complains of vaginal discharge/dysuria or vulval itching/burning

Take history and examine (external genitalia and bi-manual, use speculum)

Abnormal discharge or Any other STI vulval itching/burning NO syndrome or illness? confirmed*?

YES YES

Use appropriate flowchart, manage appropriately

Lower abdominal tenderness NO Treat with: or pain? ¥ Ciprofloxacin 500 mg stat ¥ Doxycycline 100 mg 2 x daily for 7 days ¥ Metronidazole 2 g stat**

In pregnancy / during breast feeding: YES ¥ Ceftriaxone 125 mg imi stat ¥ Erythromycin 500mg 4 x daily for 7 days ¥ Metronidazole 2 g stat**, ***

If vulval oedema/curd-like discharge, erythema, excoriations present, add: Use lower abdominal pain flowchart ¥ Clotrimazole vaginal pessary 500 mg inserted stat

Ask patient to return in 7 days if symptoms persist

Treatment failure: ¥ Symptoms/signs improved? Refer to NO ¥ Re-infection (new episode)? doctor! ¥ Poor compliance?

YES

Repeat treatment

ALL PATIENTS: Educate, ensure compliance, and counsel Promote abstinence from penetrative sex during the course of treatment Promote and demonstrate condom use, provide condoms Stress the importance of partner treatment and issue one notification slip for each sexual partner, follow up partner treatment during review visits Promote HIV counselling and testing, for negative test results repeat test after 3 months

* Confirmed by history taking or examination ** Avoid alcohol for 24 hours; alcohol during pregnancy is not recommended *** Not in first trimester: use clotrimazole vaginal pessaries for symptomatic relief in 1st trimester

SA Fam Pract 2005;47(2) 37 CPD

and diagnosis of bacterial vaginosis in a clinic of sexually were also found to be using OTC drugs evaluation alone are inadequate due to transmitted diseases. Folia Med(Plovdiv) 1998;40(1):34-40. against product recommendations. The the variable presentation of causes and 35.Reipert JF, Montagno AB, Cooper AS, et al. Bacterial vaginosis as a risk factor for upper genital tract infection. Am J Obstet main disadvantages of self-medication the presence of mixed infections. Gynecol 1997;177(5):1184-7. 36.Langsford MJ, Dobbs FF, Morrison GM, et al. The effect of are unnecessary use and use for the wrong Once a specific diagnosis is made, introduction of a guideline on the management of vaginal discharge and in particular bacterial vaginosis in primary indication. The clinical implication of this effective therapy can be provided. In a care. Fam Pract 2001;18:253-7. 37.Fleming D, Wasserheit J. From epidemiological synergy to is a delay in diagnosing and initiating small number of cases, a thorough public health policy and practice: The contribution of other sexually transmitted diseases to sexual transmission of HIV treatment for a potentially more serious investigation may fail to identify a infection. Sex Transm Infect 1999;75:3-17. 38.Amsel R, Totten PA, Spiegel CA, et al. Non-specific vaginitis. cause, such as STDs and malignancy. pathological cause. When this occurs, Diagnostic criteria and microbiological and epidemiological associations. Am J Med 1983;74:14-22. Pharmacy personnel should therefore take it is essential that the patient receive 39.Steinhandler L, Peipert JF, Heber W, et al. Combination of more responsibility in preventing incorrect adequate reassurance and support and bacterial vaginosis and leukorrhoea as a predictor of cervical chlamydia or gonococcal infections. Obstet Gynecol self-diagnosis and the continuous use of 2000;99(4):603-7. appropriate referral. 40.Thinkhamrop J, Lumbiganon P, Thongkrajai P, et al. Vaginal OTC drugs. The physician’s role in making fluid pH as a screening test for vaginitis. Int J Gynaecol Obstet 1999;66(2):143-8. the correct diagnosis at the time of 41.Nugent RP, Krohn MA, Hillier SL. Reliability of diagnosing See CPD Questionnaire, page 46 bacterial vaginosis is improved by a standardised method of consultation remains vital. Gram stain interpretation. J Clin Microbiol 1991;29:297-301. 42.Myziuk L, Romanowski B, Johnson SC. BVBlue test for Probiotics have received special Acknowledgements diagnosis of bacterial vaginosis. J Clin Microbiol 2003;41(5):1925-8. interest of late. A probiotic is a viable The authors wish to thank Ms MH Botha 43.West B, Morison L, Van der Loeff M, et al. Evaluation of a new rapid diagnostic kit (FemExam) for bacterial vaginosis microbial dietary supplement that exerts for the information supplied. in patients with vaginal discharge syndrome in the Gambia. its health benefits in the intestinal tract. Sex Transm Dis 2003;30(6):483-9. 44.Bump RC, Zuspan FP, Buesching WJ, et al. The prevalence, A prebiotic is a non-digestible food six-month persistence, and predictive values of laboratory References indicators of bacterial vaginosis (nonspecific vaginitis) in supplement that promotes commensal 1. Quan M. Diagnosis and management of infectious vaginitis. asymptomatic women. J Obstet Gynecol 1984;150:917-24. J Am Board Fam Pract 1990;3:195-205. 45.Holley RC, Richter HE, Varner RF, et al. A randomised, double- bacterial growth in the large bowel, 2. Schneider H, Blaauw D, Dartnall E, et al. STD care in the blind clinical trial of vaginal acidification versus placebo for South African private health sector. 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